provided by Nurses Service Organization (NSO) - Feb. 9

A nurse’s ability to recognize and respond to changes in a patient’s condition is a crucial element of professional nursing practice. Failure to respond appropriately to clinical changes can lead to complications and even death.¹ In a study that investigated the impact of communication in malpractice lawsuits, communication failure was a factor in 32% of cases involving nurses, with most involving poor communication with other healthcare professionals about the patient’s status. These cases often result in huge financial consequences in cost of care and legal
damages.² 

Communication

Communication of a patient’s status has been the focus of much attention and research, and various communication frameworks have been generated to facilitate clinical communication among healthcare professionals about patient status.^3,4 Widely used examples include SBAR (situation, background, assessment, and recommendation) and ISBARR (introduction, situation, background, assessment, recommendation, and read back).

In some cases, however, it is not about the nurses’ ability to communicate with primary care providers. Rather, they are about the competence and decision-making skills needed that enables a nurse to assess a patient’s condition and determine the appropriate intervention, including when to escalate care and seek the expertise of appropriate personnel.

Barriers to Communication

Many factors can play into why nurses may not communicate a patient’s status promptly or at all. These include a busy schedule, a reluctance to “bother” the primary care provider, or a failure to recognize the circumstances under which a primary care provider should be notified due to a lack of clinical competence.² Nurses need to recognize the severity and emergent nature of a patient’s condition.

A nurse’s failure to recognize an emergency indicates a lack of competence in nursing fundamentals and a lack of knowledge about the possible physiologic consequences. This gap in knowledge can contribute to a catastrophic deterioration in the patient’s condition.

Critical thinking extends beyond mere information, attentiveness, and assessment. How do nurses acquire the decision-making and critical-thinking skills necessary for their practice? The clinical competence needed to make decisions, especially in acute situations, develops over time as the nurse advances from novice to expert.⁵ 

Implications for practice

To determine appropriate interventions and recognize when it is necessary to escalate care, nurses must:

• accept only patients that they are capable of caring for.⁶
• develop the education and skills necessary to recognize when the interventions they initiate are not effective.¹
• escalate the patient’s care to a more experienced nurse or the healthcare provider when they find that a patient’s status change is beyond their capability.⁷
• follow the facility’s chain of command. A nurse’s vigilance, recognition of an urgent situation, evaluation of changes in the patient’s condition, and steps taken to escalate appropriately should be evident in the medical record.⁸ Documentation should include the persons consulted and the actions that resulted from the consultation.⁹
• be aware that nurses can be held legally liable for actions they omit as well as actions they fail to take in a timely manner.⁷

Guidelines for practice

Keep these general guidelines in mind:

• When documenting adverse events, follow your facility’s policies and procedures. The record should be objective, including only clinical facts without any guesses, assumptions, speculations about the cause of the event, or personal opinions.¹⁰
• Listen to family members’ concerns. They are often at the bedside much longer than the clinical staff. They know the patient and are likely already engaging in the care of the patient at home. They are a valuable source of information and their concerns should be taken seriously.¹¹
• Nurses should consider carrying their own liability insurance, both for the purposes of legal liability and for any disciplinary actions taken by the board of nursing.¹²

The failure to report changes in a patient’s condition can have serious health consequences for the patient as well as legal and financial implications for all involved in the care of the patient. But by meeting the standards of professional nursing care, nurses can and should avoid these costly consequences.

REFERENCES

1. Massey D, Chaboyer W, Anderson V. What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature. Nurs Open. 2016;4(1):6-23.
2. Crico Strategies. Malpractice risks in communication failures. 2015 Annual benchmarking report. www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures.
3. Institute for Healthcare Improvement. SBAR Tool: Situation-Background-Assessment-Recommendation. www.ihi.org/resources/Pages/Tools/sbartoolkit.aspx.
4. Cudjoe KG. Add identity to SBAR. Nurs Made Incredibly Easy. 2016;14(1):6-7.
5. Benner P. From novice to expert. Am J Nurs. 1982;82(3):402-407.
6. Buppert C. A “safe harbor” for unsafe nursing assignments. Medscape. April 26, 2019.
7. Nurses Service Organization. Failure to report changes in the patient’s medical condition to practitioner. 2012. www.nso.com/Learning/Artifacts/Legal-Cases/Failure-to-report-changes-in-the-patients-medical-condition-to-practitioner.
8. Thielen J. Failure to rescue as the conceptual basis for nursing clinical peer review. J Nurs Care Qual. 2014;29(2):155-163.
9. American Nurses Association. ANA’s Principles for Nursing Documentation: Guidance for Registered Nurses. Silver Spring, MD: American Nurses Association; 2010. 
10. Austin S. Stay out of court with proper documentation. Nursing. 2011;41(4):24-29.
11. Sherman DW. A review of the complex role of family caregivers as health team members and second-order patients. Healthcare (Basel). 2019;7(2):63.
12. Brous E. Reciprocal enforcement and other collateral issues with licensure discipline. J Nurse Pract. 2017;13(2):118-122.

By Omobola Awosika Oyeleye, EdD, JD, MSN, MEd, RN-BC, CNE, CHSE
This article has been adapted for space and originally appeared in the November 2019 issue of Nursing © 2019 Wolters Kluwer Health, Inc.

This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to service@nso.com or call 1-800-247-1500. www.nso.com.